Category Archives: Procedures

Scooped yet again! Teaching Point on a Non-Traditional IO Application

One of my senior residents, now graduated and a fancy informatics fellow and general badass at Stanford, Christian Rose and I used to discuss how we wondered if in extenuating circumstances one could use an intraosseous drill / needle to trephine a skull and drain a rapidly-expanding intraaxial hematoma in a crashing patients. Like most emergency medicine doctors, I find life-saving procedures interesting and cool and even though I would never want the lifestyle that accompanies neurosurgery, being able to do these interventions in a resource-limited setting is something I aspire to if it had to be done. (I’ve seen a burr hole and clot evacuation done once by an ED physician who had been trained in the military and done them abroad in forward operating theaters — he borrowed a drill from the ortho OR. It was successful, appeared fairly easy, and saved a life.)

This was all just theoretical until I read this post from the EMCore conference blog by Peter Kas. He relates a story recently published as a case report in Injury of using an EZ-IO drill and a 25 mm 15 ga intraosseous needle to drain a rapidly-expanding epidural hematoma in a pedestrian who was struck by an auto who presented and had a rapid decline in GCS and clinical signs of herniation. This procedure took about 8 minutes — shaving and sterilizing the scalp, and was done in the anesthesiology prep area while the neurosurgeons prepped for a craniotomy. They were able to aspirate ~ 30 mL of blood, with resulting improvement in the pupillary exam. A formal craniotomy was completed, and the patient had a good outcome. 

The authors note that this is unlikely to provide definitive management, given that most significant hematoma requiring craniotomy are of a more solid consistency that would be difficult to drain entirely via this route, but that it might be utilized by ED providers needing to transfer a patient over a long distance to definitive care. They specifically describe how they envision the procedure:

We propose the site of insertion should be the point of maximal clot depth and therefore localisation of the insertion point would be on a case by case basis. Most extradural haematomas requiring emergency craniotomy are of sufficient size that we postulate that failure to place the needle into the haematoma is unlikely but a potential complication.

Anyway, fun fact of the day, and perhaps someday (hopefully this will never come up) a last-ditch hail mary move that is a little easier and possibly safer/faster than borrowing a drill from your local orthopod and hoping you don’t go too deep.


Bulstrode H1, Kabwama S2, Durnford A3, Hempenstall J4, Chakraborty A5. Temporising extradural haematoma by craniostomy using an intraosseous needle. Injury. 2017 May;48(5):1098-1100. PMID: 28238447. [PubMed] [Read by QxMD]